Exploring atypical spatial-functional coupling in adolescent autism spectrum disorder: insights from neurodevelopment and transcriptomic architecture.

Acute subdural hematoma (ASDH) is the most prevalent pathology associated with traumatic brain injury (TBI) (). ASDHs causing a remarkable mass effect typically warrant immediate surgical evacuation. Early removal of space-occupying lesions can reduce intracranial hypertension and prevent brain herniation. The mainstay of surgical treatment is hematoma removal through a large craniotomy or decompressive craniectomy (). However, it remains unclear whether either is associated with better outcomes for ASDH. When craniotomy is chosen as a management option in appropriately selected ASDH cases, a less invasive alternative may be a good choice. Neuroendoscopy through a small bone flap can accommodate minimally invasive instruments and achieve the safe removal of hematoma, as evidenced by favorable results in treating elderly patients with ASDH (). The shrinking volume within the elderly cranial vault provides technical feasibility for a series of endoscopic performances. Nevertheless, in younger patients without brain atrophy, it is worth studying whether endoscopic surgery for ASDH could still demonstrate technical superiority. Similar reports are rare (, ). Herein, we present the endoscopic procedure for ASDH in two young patients without preoperative deterioration and discuss the treatment challenges. A 39-year-old man with a history of schizophrenia and chronic alcoholism presented with a severe headache for 11 h and an epileptiform seizure after falling at home. A brain computed tomography (CT) scan showed an acute subdural hematoma with a thickness of 13.02 mm in the right frontotemporoparietal region, a midline shift of 6.61 mm, compression of the right ventricle, and traumatic subarachnoid hemorrhage (SAH) (). The patient's vital signs were stable, and the Glasgow Coma Scale (GCS) was 15. After being admitted to the trauma intensive care unit, he gradually developed delirium, agitation, and aggression. Although the patient's abnormal behavior might be highly related to his history, we had to first attribute it to the elevated intracranial pressure. In the absence of herniation, endoscopic surgery with general anesthesia was scheduled 40 h later with no progressive findings on repeated CT before surgery. The patient was placed in the lateral position. A curvilinear scalp incision was made to locate the thickest portion of the hematoma, partly coinciding with the conventional reverse question mark approach, which could facilitate conversion to craniotomy (). A 3-cm-diameter bone flap was created (). The dura was incised in a cruciform after being suspended, exposing a dark hematoma around the opening, which was removed under direct vision and irrigated with saline. Then, a rigid endoscope with a 0° angle and a 4 mm diameter (Karl Storz Endoskope, Tuttlingen, Germany) was introduced. Initially, the space of the subdural collection was too narrow to maneuver the endoscope and irrigation suction cannula deeper until air was gradually displaced into the hematoma cavity in the lateral position with no tilt. Almost all hematomas were evacuated. After saline irrigation and endoscopy revealed no other bleeding points, a silicone drain was inserted into the subdural space. The dura mater was closed, the bone flap was repositioned, and the skin was closed. Postoperative CT showed adequate hematoma resolution and a significant decrease in the mass effect (). The patient's headache notably alleviated, and the aberrant manifestations disappeared immediately. After an additional 9 days of postoperative care, the patient was uneventfully discharged. Head CT scan showing a thick acute right-sided subdural hematoma and remarkable midline shift at the time of admission. Curvilinear incision (white arrow) could facilitate conversion to a possible craniotomy. The measured size of the bone flap was 3 cm. Follow-up CT on immediate postoperation, 4, and 25 days later, respectively.